Recognising older frail patients near the end of life: What next?

Prognostic accuracy of eight frailty instruments for all-cause mortality in Australian primary care

AIM

To investigate the ability of eight frailty instruments to accurately predict all-cause mortality and other adverse outcomes in Australian primary care patients.

METHODS

Study participants included adults aged ≥75 years attending one of three primary care clinics in South Australia. Frailty instruments studied were Fried's frailty phenotype (FFP), the Frailty Index (FI) of cumulative deficits, Kihon Checklist (KCL), the Fatigue Resistance Ambulation Illness and Loss of weight (FRAIL) scale, Groningen Frailty Indicator (GFI), PRISMA-7, Reported Edmonton Frail Scale (REFS), and gait speed. Primary outcomes were all-cause mortality at 12- and 24-months. Secondary outcomes included falls, general practice attendance, hospital admission and emergency department (ED) presentation at 12-months.

RESULTS

243 participants (55.6 % female) with a mean (SD) age of 80.2 (4.6) years were included. 29 participants (16.6 %) were classified as frail at baseline by FFP. All frailty instruments demonstrated a significant ability to predict 12- and 24-month mortality. The REFS showed the highest auROC for both 12- and 24-month mortality. The REFS, Frailty Index, Kihon Checklist, FRAIL scale, and gait speed showed excellent discriminative ability for 12-month mortality (auROC ≥ 0.8 - >0.9), while the remainder showed acceptable discrimination. All frailty instruments, with the exception of the GFI, showed an excellent discriminative ability for 24-month mortality (auROC 0.8-<0.9).

CONCLUSIONS

All frailty instruments possessed adequate discriminative ability for all-cause mortality predicting in older primary care patients. Frailty measurement is thus a valuable strategy to identify older patients at risk of mortality and can guide clinical decision-making in primary care settings.

Impact of frailty on the short-term outcomes of elderly intensive care unit patients

BACKGROUND

Frailty leads to multiple unfavourable outcomes in older adults. However, few studies have investigated correlations between frailty and its impacts on morbidity and mortality of elderly patients in intensive care units (ICUs) in Taiwan.

AIMS

To investigate the impact of frailty on the risk of hospital and 30-day mortality and functional outcomes of elderly Taiwanese ICU patients.

STUDY DESIGN

A prospective observational study was conducted. Patients aged 65 years or older were recruited from three medical ICUs. We defined 'frailty' according to the Clinical Frailty Scale (CFS) higher than 4 within 1 month prior to admission. The primary outcomes were hospital and 30-day mortality. The secondary outcome was CFS changes at ICU admission, hospital discharge, and 30-day follow-up. Logistic/Cox regression was used to analyse the data.

RESULTS

We recruited a total of 106 patients, 57 (54%) of whom were classified as frail. The overall mortality rate was 21%. Hospital mortality and mortality within 30 days after discharge were higher in the frail patients without a significant statistical difference (hospital mortality: 17.5% vs. 12.2%, p = .626; 30-day mortality: 26.3% vs. 14.3%, p = .200). The risk of 30-day mortality for frail patients was up to 2.84 times greater than that of non-frail patients in the Cox model (hazard ratio = 2.84, 95% confidence interval [0.96, 8.38]). Both non-frail and frail patients had a worse CFS score on admission, but the CFS score of surviving non-frail patients improved significantly over the medium term.

CONCLUSION

Frailty tended to increase short-term ICU mortality risk and worsen functional outcomes in the elderly Taiwanese population. This information might guide critical medical decisions.

RELEVANCE TO CLINICAL PRACTICE

Frailty could be included in the prognostic evaluation of either mortality risk or functional outcome. Prompt palliative care might be one last piece of holistic elder care.

Frailty trajectories and associated factors in the years prior to death: evidence from 14 countries in the Survey of Health, Aging and Retirement in Europe

BACKGROUND

Age-related changes in frailty have been documented in the literature. However, the evidence regarding changes in frailty prior to death is scarce. Understanding patterns of frailty progression as individuals approach death could inform care and potentially lead to interventions to improve individual's well-being at the end of life. In this paper, we estimate the progression of frailty in the years prior to death.

METHODS

Using data from 8,317 deceased participants of the Survey of Health, Ageing, and Retirement in Europe, we derived a 56-item Frailty Index. In a coordinated analysis of repeated measures of the frailty index in 14 countries, we fitted growth curve models to estimate trajectories of frailty as a function of distance to death controlling both the level and rate of frailty progression for age, sex, years to death and dementia diagnosis.

RESULTS

Across all countries, frailty before death progressed linearly. In 12 of the 14 countries included in our analyses, women had higher levels of frailty close to the time of death, although they progressed at a slower rate than men (e.g. Switzerland (-0.008, SE = 0.003) and Spain (-0.004, SE = 0.002)). Older age at the time of death and incident dementia were associated with higher levels and increased rate of change in frailty, whilst higher education was associated with lower levels of frailty in the year preceding death (e.g. Denmark (0.000, SE = 0.001)).

CONCLUSION

The progression of frailty before death was linear. Our results suggest that interventions aimed at slowing frailty progression may need to be different for men and women. Further longitudinal research on individual patterns and changes of frailty is warranted to support the development of personalized care pathways at the end of life.

A Consensus Definition of End of Life from an International and Interdisciplinary Perspective: A Delphi Panel Study

Background: Those working in the field of palliative care have recognized that many terms are being used synonymously and that clear definitions (or any definitions) for many of these terms are lacking. The synonymous use of the terms palliative and end of life (EOL) can especially lead to conflicts in clinical practice, such as a tardy referral to palliative care. Such conflicts may then result in poorer treatment of patients, for instance, pain management. In research, the lack of clear definitions or even of any established definition for central concepts, such as EOL, weakens study validity and research outcomes. Objective: The aim of this study was to establish a concise definition for the EOL phase. Design: A modified Delphi study design was chosen. A structured questionnaire based on a previously conducted concept analysis about the EOL was used. Setting: A panel of international and interdisciplinary experts was established. Between 34 (1st round) and 21 (4th round) individuals participated in the anonymous online expert panel. Results: After four panel rounds, we were able to provide a definition which covers physical and psychosocial aspects that should be considered at the beginning of the EOL phase and possible predictions about the remaining time. The definition also covers aspects of EOL care, such as considerations related to the individual's dignity, spirituality, and maintenance of relationships. Conclusion: EOL is a term which is defined by considering multiple aspects that affect the process of identifying the EOL phase, the EOL phase itself and the resulting care options.

'End of life': a concept analysis

BACKGROUND

The concept of end of life (EOL), as in the term end-of-life care, is used synonymously in both palliative and terminal care. Practitioners and researchers both require a clearer specification of the end-of-life concept to be able to provide appropriate care in this phase of life and to conduct robust research on a well-described theoretical basis.

AIMS

The aim of this study was to critically analyse the end-of-life concept and its associated terminology.

METHOD

A concept analysis was performed by applying Rodgers' evolutionary concept analysis method.

FINDINGS

Time remaining, clinical status/physical symptoms, psychosocial symptoms and dignity were identified as the main attributes of the concept. Transition into the end-of-life phase and its recognition were identified as antecedents. This study demonstrates that end-of-life care emerged following the application of the 'end-of-life concept' to clinical practice.

CONCLUSION

The early recognition of the end-of-life phase seems to be crucial to ensuring an individual has well-managed symptoms and a dignified death.

Impact of frailty on all-cause mortality or major amputation in patients with lower extremity peripheral artery disease: A meta-analysis

BACKGROUND

Frailty has been increasingly identified as a risk factor of adverse outcomes in vascular disease. However, its impact on the survival and amputation in patients with lower extremity peripheral artery disease (PAD) remains controversial. This meta-analysis aimed to examine the value of frailty in predicting all-cause mortality or major amputation in patients with lower extremity PAD.

METHODS

PubMed, Embase, Web of Sciences, and Scopus databases (up to April 7, 2022) were comprehensively searched to identify relevant studies that investigated the association between frailty and all-cause mortality or major amputation in patients with lower extremity PAD. The impact of frailty on adverse outcomes was summarized by pooling the fully adjusted hazard ratio (HR) with 95% confidence intervals (CI) using a random effect (DerSimonian-Laird) model.

RESULTS

Seven studies reporting on eight articles that involved 122,892 patients were included. The prevalence of frailty ranged from 42% to 80% based on the frailty tool used. Meta-analysis showed that frailty was associated with an increased risk of 30-day all-cause mortality (HR 2.11; 95% CI 1.41-3.15; I² =47.6%, p = 0.148, Tau-squared=0.058) and long-term all-cause mortality (HR 1.86; 95% CI 1.25-2.76; I² =76.1%, p = 0.002, Tau-squared=0.118). However, no clear association was observed between frailty and major amputation (HR 1.07; 95% CI 0.83-1.36; I² =23.0%, p = 0.273, Tau-squared=0.019).

CONCLUSION

Frailty independently predicts short and long-term all-cause mortality but not major amputation in patients with lower extremity PAD. Frailty status may play an important role in risk stratification of lower extremity PAD.

Assessment of frailty in elderly patients attending a multidisciplinary wound care centre: a cohort study

BACKGROUND

The incidence of frailty and non-healing wounds increases with patients' age. Knowledge of the relationship between frailty and wound healing progress is greatly lacking.

METHODS

The aim of this study is to characterize the degree of frailty in elderly patients attending a multidisciplinary wound care centres (MWCC). Additionally, we seek to assess the impact of frailty on the wound healing rate and wound healing time. An open cohort study was conducted on 51 consecutive patients aged > 70 years treated for wounds at an MWCC of an intermediate care hospital. The frailty score was determined according to the Frail-VIG index. Data were collected through patient questionnaires at the beginning of the study, and at 6 months or upon wound healing. Wounds were followed up every 2 weeks. To analyse the relationship between two variables was used the Chi-square test and Student's or the ANOVA model. The t-test for paired data was used to analyse the evolution of the frailty index during follow-up.

RESULTS

A total of 51 consecutive patients were included (aged 81.1 ± 6.1 years). Frailty prevalence was 74.5% according to the Frail-VIG index (47.1% mildly frail, 19.6% moderately frail, and 7.8% severely frail). Wounds healed in 69.6% of cases at 6 months. The frailty index (FI) was higher in patients with non-healing wounds in comparison with patients with healing wounds (IF 0.31 ± 0.15 vs IF 0.24 ± 0.11, p = 0.043). A strong correlation between FI and wound healing results was observed in patients with non-venous ulcers (FI 0.37 ± 0.13 vs FI 0.27 ± 0.10, p = 0.015). However, no correlation was observed in patients with venous ulcers (FI 0.17 ± 0.09 vs FI 0.19 ± 0.09, p = 0.637). Wound healing rate is statically significantly higher in non-frail patients (8.9% wound reduction/day, P25-P75 3.34-18.3%/day;AQ6 p = 0.044) in comparison with frail patients (3.26% wound reduction/day, P25-P75 0.8-8.8%/day).

CONCLUSION

Frailty is prevalent in elderly patients treated at an MWCC. Frailty degree is correlated with wound healing results and wound healing time.

Identifying older adults with frailty approaching end-of-life: A systematic review

BACKGROUND

People with frailty may have specific needs for end-of-life care, but there is no consensus on how to identify these people in a timely way, or whether they will benefit from intervention.

AIM

To synthesise evidence on identification of older people with frailty approaching end-of-life, and whether associated intervention improves outcomes.

DESIGN

Systematic review (PROSPERO: CRD42020462624).

DATA SOURCES

Six databases were searched, with no date restrictions, for articles reporting prognostic or intervention studies. Key inclusion criteria were adults aged 65 and over, identified as frail via an established measure. End-of-life was defined as the final 12 months. Key exclusion criteria were proxy definitions of frailty, or studies involving people with cancer, even if also frail.

RESULTS

Three articles met the inclusion criteria. Strongest evidence came from one study in English primary care, which showed distinct trajectories in electronic Frailty Index scores in the last 12 months of life, associated with increased risk of death. We found no studies evaluating established clinical tools (e.g. Gold Standards Framework) with existing frail populations. We found no intervention studies; the literature on advance care planning with people with frailty has relied on proxy definitions of frailty.

CONCLUSION

Clear implications for policy and practice are hindered by the lack of studies using an established approach to assessing frailty. Future end-of-life research needs to use explicit approaches to the measurement and reporting of frailty, and address the evidence gap on interventions. A focus on models of care that incorporate a palliative approach is essential.

A rapid scoping review of end-of-life conversations with frail older adults in Canada

OBJECTIVE

To explore what is known about end-of-life (EOL) conversations with frail older adults across all settings including primary care in Canada, and to understand the barriers to, and recommendations for, EOL conversations.

DATA SOURCES

Comprehensive searches were conducted in CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), AgeLine (EBSCO), Sociological Abstracts (ProQuest), and Applied Social Sciences Index and Abstracts (ProQuest). Searches used text words and subject headings (eg, MeSH, Emtree) related to 3 concepts: frailty, Canada, and EOL conversations.

STUDY SELECTION

Twenty-one English-language articles were selected (ie, 4 reviews, 10 commentaries, 3 quantitative studies, 3 qualitative studies, 1 mixed-methods study) that included information about EOL conversations with frail older adults in the Canadian health care context.

SYNTHESIS

In terms of having EOL conversations with frail older adults, this study found that many clinicians do not often and adequately discuss frailty and impending death with their older patients. Moreover, patients and their care partners do not have enough knowledge about frailty and death to make informed EOL decisions, leading to patients choosing more aggressive therapies instead of care focused on symptom management. In terms of barriers to EOL discussions, common barriers included a lack of trust between clinician and patient, inadequate EOL training for clinicians, and ineffective clinician communication with patients and families. Recommendations for improving EOL conversations include regular screening for frailty to prompt conversations about care and the use of an interprofessional approach.

CONCLUSION

More empirical research is needed that uses exploratory methods to shed light on the contextual factors that may act as a barrier to EOL conversations. More research is also needed on the roles and responsibilities of interprofessional teams in screening for frailty and engaging in EOL conversations. Moreover, there is a need to better understand how frail older patients and their families want EOL conversations to unfold and what best facilitates these conversations.

Virtual Cohorts and Synthetic Data in Dementia: An Illustration of Their Potential to Advance Research

When attempting to answer questions of interest, scientists often encounter hurdles that may stem from limited access to existing adequate datasets as a consequence of poor data sharing practices, constraining administrative practices. Further, when attempting to integrate data, differences in existing datasets also impose challenges that limit opportunities for data integration. As a result, the pace of scientific advancements is suboptimal. Synthetic data and virtual cohorts generated using innovative computational techniques represent an opportunity to overcome some of these limitations and consequently, to advance scientific developments. In this paper, we demonstrate the use of virtual cohorts techniques to generate a synthetic dataset that mirrors a deeply phenotyped sample of preclinical dementia research participants.

Frailty degree and illness trajectories in older people towards the end-of-life: a prospective observational study

OBJECTIVES

To assess the degree of frailty in older people with different advanced diseases and its relationship with end-of-life illness trajectories and survival.

METHODS

Prospective, observational study, including all patients admitted to the Acute Geriatric Unit of the University Hospital of Vic (Spain) during 12 consecutive months (2014-2015), followed for up to 2 years. Participants were identified as end-of-life people (EOLp) using the NECPAL (NECesidades PALiativas, palliative care needs) tool and were classified according to their dominant illness trajectory. The Frail-VIG index (Valoración Integral Geriátrica, Comprehensive Geriatric Assessment) was used to quantify frailty degree, to calculate the relationship between frailty and mortality (Receiver Operating Characteristic (ROC) curves), and to assess the combined effect of frailty degree and illness trajectories on survival (Cox proportional hazards model). Survival curves were plotted using the Kaplan-Meier estimator with participants classified into four groups (ie, no frailty, mild frailty, moderate frailty and advanced frailty) and were compared using the log-rank test.

RESULTS

Of the 590 persons with a mean (SD) age of 86.4 (5.6) years recruited, 260 (44.1%) were identified as EOLp, distributed into cancer (n=31, 11.9%), organ failure (n=79, 30.4%), dementia (n=86, 33.1%) and multimorbidity (n=64, 24.6%) trajectories. All 260 EOLp had some degree of frailty, mostly advanced frailty (n=184, 70.8%), regardless of the illness trajectory, and 220 (84.6%) died within 2 years. The area under the ROC curve (95% CI) after 2 years of follow-up for EOLp was 0.87 (0.84 to 0.92) with different patterns of survival decline in the different end-of-life trajectories (p<0.0001). Cox regression analyses showed that each additional deficit of the Frail-VIG index increased the risk of death by 61.5%, 30.1%, 29.6% and 12.9% in people with dementia, organ failure, multimorbidity and cancer, respectively (p<0.01 for all the coefficients).

CONCLUSIONS

All older people towards the end-of-life in this study were frail, mostly with advanced frailty. The degree of frailty is related to survival across the different illness trajectories despite the differing survival patterns among trajectories. Frailty indexes may be useful to assess end-of-life older people, regardless of their trajectory.

Progression of Physical Frailty and the Risk of All-Cause Mortality: Is There a Point of No Return?

OBJECTIVES

To investigate the rate and patterns of accumulation of frailty manifestations in relationship to all-cause mortality and whether there is a point in the progression of frailty beyond which the process becomes irreversible and death becomes imminent (a.k.a. point of no return).

DESIGN

Longitudinal observational study.

SETTING

Community or a non-nursing home residential care setting.

PARTICIPANTS

Two thousand five hundred and fifty seven robust older adults identified at baseline in 2011 with follow-up for all-cause mortality between 2011 and 2018.

MEASUREMENTS

Frailty was measured by the physical frailty phenotype. Cox models were used to study the relationships of the number of frailty criteria (0-5) at each point in time and its accumulation patterns with all-cause mortality. Markov state-transition models were used to study annual transitions between health states (i.e., frailty, recovery, and death) after becoming frail among those with frailty onset (n = 373).

RESULTS

There was a nonlinear association between greater number of frailty criteria and increasing risk of mortality, with a notable risk acceleration after having accumulated all five criteria (hazard ratio (HR) = 32.6 vs none, 95% confidence interval (CI) = 15.7-67.5). In addition, the risk of one-year mortality tripled, and the likelihood of recovery (i.e., reverting to be robust or pre-frail) halved among those with five frailty criteria compared to those with three or four criteria. A 50% increase in mortality risk was also associated with frailty onset without (vs with) a prior history of pre-frailty (HR = 1.51, 95% CI = 1.20-1.90).

CONCLUSION

Both the number and rate of accumulation of frailty criteria were associated with mortality risk. Although there was insufficient evidence to declare a point of no return, having all five-frailty criteria signals the beginning of a transition toward a point of no return. Ongoing monitoring of frailty progression could aid clinical and personal decision-making regarding timing of intervention and eventual transition from curative to palliative care.

Prevalence and predictors of mortality for older adults referred to hospital avoidance program

AIM

Following discharge from a hospital avoidance program, to examine the prevalence of patient mortality, demographic characteristics associated with risk of mortality up to 33 months, patient demographic and health characteristics associated with mortality within 1 year.

METHODS

A retrospective data linkage study of older adults with mean age of 80.5 years discharged from a hospital avoidance program between January 2017 and January 2018. The prevalence of death at 3, 6, 12, 18 and 33 months was calculated. Patient demographic and health characteristics associated with participant mortality within 12 (n = 195) and 33 (n = 185) months of discharge was examined using Cox multivariable regression for patients with complete health characteristic data.

RESULTS

The mortality prevalence was 17% at 6 months and cumulative prevalence at 1 year, 18 months and 33 months post-discharge were 24%, 29% and 36% respectively. Characteristics associated with mortality within 12 months of discharge were lower cognition, increased burden of comorbidity, decreased physical function, weight <55 kg and male sex. The same variables were associated with death up to 33 months as well as age, interaction between household arrangement and time, and albumin.

CONCLUSIONS

The establishment of potential risk indicators allows greater specificity for identifying older people at risk of dying in the next 12 months and an opportunity to discuss their advanced care planning. Geriatr Gerontol Int 2021; ••: ••-••.

The Importance of Taking a Patient-Centered, Community-Based Approach to Preventing and Managing Frailty: A Public Health Perspective

Across the world, life expectancy is increasing. However, the years of life gained do not always correspond to healthy life years, potentially leading to an increase in frailty. Given the extent of population aging, the association between frailty and age and the impact of frailty on adverse outcomes for older people, frailty is increasingly being recognized to be a significant public health concern. Early identification of the condition is important to help older adults regain function and to prevent the negative outcomes associated with the syndrome. Despite the importance of diagnosing frailty, there is no definitive evidence or consensus of whether screening should be routinely implemented. A broad range of screening and assessment instruments have been developed taking a biopsychosocial approach, characterizing frailty as a dynamic state resulting from deficits in any of the physical, psychological and social domains, which contribute to health. All these aspects of frailty should be identified and addressed using an integrated and holistic approach to care. To achieve this goal, public health and primary health care (PHC) need to become the fulcrum through which care is offered, not only to older people and those that are frail, but to all individuals, favoring a life-course and patient-centered approach centered around integrated, community-based care. Public health personnel should be trained to address frailty not merely from a clinical perspective, but also in a societal context. Interventions should be delivered in the individuals' environment and within their social networks. Furthermore, public health professionals should contribute to education and training on frailty at a community level, fostering community-based interventions to support older adults and their caregivers to prevent and manage frailty. The purpose of this paper is to offer an overview of the concept of frailty for a public health audience in order to raise awareness of the multidimensional aspects of frailty and on how these should be addressed using an integrated and holistic approach to care.

Biomedicalization of end-of-life conversations with medically frail older adults - Malleable and senescent bodies

The common practice of delaying and/or avoiding end-of-life conversations with medically frail older adults is an important clinical issue. Most research investigating this practice focuses on clinician training and developing conversation skills. Little is known about the socio-political factors shaping the phenomenon of end-of-life conversations between clinicians and medically frail older patients. Using the critical lens of biomedicalization we consider how two dominant discourses, successful aging and frailty, and subsequent constructions of bodies as malleable or senescent, shape patient subjectivities and influence normative expectations about appropriate healthcare conversations and the consumption of biomedicine for medically frail adults. We highlight the uneven ways medically frail older adults are clinically positioned as successful or frail agers and briefly discuss how gender, class, and race may impact this tension and ambiguity. We conclude by arguing that end-of-life conversations with medically frail older adults is constrained by the pervasiveness of the successful aging discourse and the tendency within medical institutions to construct older bodies as malleable and in need of medical intervention to promote health and longevity.

Experiences of oldest-old caregivers whose partner is approaching end-of-life: A mixed-method systematic review and narrative synthesis

Population ageing has rapidly increased the number of people requiring end-of-life care across the globe. Governments have responded by promoting end-of-life in the community. Partly as a consequence, older spouses are frequently providing for their partner's end-of-life care at home, despite potentially facing their own health issues. While there is an emerging literature on young-old caregivers, less is known about spouse carers over 75 who are likely to face specific challenges associated with their advanced age and relationship status. The aim of this review, therefore, is to identify and synthesise the literature concerning the experiences of caregiver's aged 75 and over whose partner is approaching end-of-life. We conducted a mixed-method systematic review and narrative synthesis of the empirical literature published between 1985 and May 2019, identified from six databases: Medline, PsychINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Sociological Abstracts and Social Service Abstracts. Hand searching and reference checking were also conducted. Gough's Weight of Evidence and Morgan's Feminist Quality Appraisal tool used to determine the quality of papers. From the initial 7819 titles, 10 qualitative studies and 9 quantitative studies were included. We identified three themes: 1) "Embodied impact of care" whereby caring was found to negatively impact carers physical and psychological health, with adverse effects continuing into bereavement; 2) "Caregiving spouse's conceptualisation of their role" in which caregiver's navigated their self and marriage identities in relation to their partner's condition and expectations about gender and place; 3) "Learning to care" which involved learning new skills and ways of coping to remain able to provide care. We identified a recent up-surge in published papers about very old spousal caregivers, which now comprise a small, medium-quality evidence base. This review outlines a range of potential lines of inquiry for future research including further clarification of the impact of caregiving on the likelihood of mortality, the incidence of men and women providing end-of-life care amongst this age group, and the role of anticipatory grief in shaping their perceptions of their relationship and their own longevity.

Preferences for End-of-Life Care and Decision Making Among Older and Seriously Ill Inpatients: A Cross-Sectional Study

CONTEXT

Older and seriously ill Australians are often admitted to hospital in the last year of their life. The extent to which these individuals have considered important aspects of end-of-life (EOL) care, including location in which care is provided, goals of care, and involvement of others in decision making, is unclear.

OBJECTIVES

To determine, in a sample of older and seriously ill Australian inpatients, preferences regarding location in which they receive EOL care and reasons for their choice; who is involved in EOL decisions; disclosure of life expectancy; goals of care; and voluntary-assisted dying.

METHODS

Cross-sectional face-to-face survey interviews conducted with 186 (80% consent) inpatients in a tertiary referral center aged 80 years and older; or aged 55 years and older with progressive chronic disease(s); or with physician-estimated life expectancy of less than 12 months.

RESULTS

Home care was preferred (69%), given the perceived availability of family/friends, familiarity of environment, and likelihood of having wishes respected. If unable to make decisions themselves, inpatients wanted family to decide care alone (31%) or with a doctor (49%). Of those who had not discussed life expectancy, 23% wished to. Most (76%) preferred care that maintained quality of life and relieved symptoms. There was some agreement for being sedated at the EOL (63%) and able to access medication to end life (43%).

CONCLUSION

Most inpatients would prefer EOL care that maintains quality and relieves suffering compared with life extension and to receive this care at home. Family involvement in resolution and documentation of EOL decisions should be prioritized.

The Prevalence of Frailty by the FRAIL-NH Scale in Taiwan Nursing Home Residents

INTRODUCTION

The prevalence of frailty defined by FRAIL-NH varies among different studies in nursing homes, ranging from 19.0% to 75.6%. This study investigated the prevalence of frailty in a nursing home in Taiwan using different diagnostic criteria for frailty.

METHODS

The 7-item FRAIL-NH scale was used for assessing frailty. There are 7 components: fatigue, resistance, mobility, incontinence or disease, weight loss, eating style and assistance with dressing. Each item is worth 0, 1, or 2 points for a total score of 14 points. We sorted and summarized the patients, according to the number of variables, into the not frail, frail, and most frail groups. Descriptive analysis was applied to understand the basic attributes of the elderly with different degrees of frailty, the influencing factors of frailty, and the occurrence of frailty.

RESULTS

Our final sample included 34 residents. They were aged between 56 and 100 years (mean age 83.91 ± 10.84), and 18 (52.94%) were female. The frail group revealed a higher prevalence of males than of females. The marital status composition of participants was as follows: 2 (5.88%) unmarried, 24 (70.59%) married, and 8 (23.53%) widowed. The mean FRAIL-NH score was 5.79±3.72.

CONCLUSIONS

A significant prevalence of frailty defined by FRAIL-NH was observed in a nursing home in Taiwan. Our findings indicate that frailty is an important issue in nursing homes. Further prospective cohort studies using FRAIL-NH evaluation are warranted.

Uncertain trajectories in old age and implications for families and for palliative and end of life care policy and practice

The provision of high-quality end-of-life care for all is high on national (and international) agendas, but areas of unmet needs identified includes elderly people. This article draws on an autoethnographic account of the dying and death of my father to identify and interrogate disjunctions between end-of-life care policy and commonplace experiences of elderly people who die in a hospital setting. There are significant disjunctions between the "blunt" tools of end-of-life care policy and the everyday experiences of the dying and death of an elderly patient and an urgent need to improve end-of-life care for our oldest generations.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

OBJECTIVE

The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults.

METHODS

These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Which frailty scale for patients admitted via Emergency Department? A cohort study

OBJECTIVES

To determine the prevalence of frailty in Emergency Departments (EDs); examine the ability of frailty to predict poor outcomes post-discharge; and identify the most appropriate instrument for routine ED use.

METHODS

In this prospective study we simultaneously assessed adults 65+yrs admitted and/or spent one night in the ED using Fried, the Clinical Frailty Scale (CFS), and SUHB (Stable, Unstable, Help to walk, Bedbound) scales in four Australian EDs for rapid recognition of frailty between June 2015 and March 2016.

RESULTS

899 adults with complete follow-up data (mean (SD) age 80.0 (8.3) years; female 51.4%) were screened for frailty. Although different scales yielded vastly different frailty prevalence (SUHB 9.7%, Fried 30.4%, CFS 43.7%), predictive discrimination of poor discharge outcomes (death, poor self-reported health/quality of life, need for community services post-discharge, or reattendance to ED after the index hospitalization) for all identical final models was equivalent across all scales (AUROC 0.735 for Fried, 0.730 for CFS and 0.720 for SUHB).

CONCLUSION

This study confirms that screening for frailty in older ED patients can inform prognosis and target discharge planning including community services required. The CFS was as accurate as the Fried and SUHB in predicting poor outcomes, but more practical for use in busy clinical environments with lower level of disruption. Given the limitations of objectively measuring frailty parameters, self-report and clinical judgment can reliably substitute the assessment in EDs. We propose that in a busy ED environment, frailty scores could be used as a red flag for poor follow-up outcome.

Predictive validity of the CriSTAL tool for short-term mortality in older people presenting at Emergency Departments: a prospective study

ABSTRACT

To determine the validity of the Australian clinical prediction tool Criteria for Screening and Triaging to Appropriate aLternative care (CRISTAL) based on objective clinical criteria to accurately identify risk of death within 3 months of admission among older patients.

METHODS

Prospective study of ≥ 65 year-olds presenting at emergency departments in five Australian (Aus) and four Danish (DK) hospitals. Logistic regression analysis was used to model factors for death prediction; Sensitivity, specificity, area under the ROC curve and calibration with bootstrapping techniques were used to describe predictive accuracy.

RESULTS

2493 patients, with median age 78-80 years (DK-Aus). The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% CI 7.7-8.6 vs. 5.8 95% CI 5.6-5.9) and Danish mean 7.1 (95% CI 6.6-7.5 vs. 5.5 95% CI 5.4-5.6). The model with Fried Frailty score was optimal for the Australian cohort but prediction with the Clinical Frailty Scale (CFS) was also good (AUROC 0.825 and 0.81, respectively). Values for the Danish cohort were AUROC 0.764 with Fried and 0.794 using CFS. The most significant independent predictors of short-term death in both cohorts were advanced malignancy, frailty, male gender and advanced age. CriSTAL's accuracy was only modest for in-hospital death prediction in either setting.

CONCLUSIONS

The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) has good discriminant power to improve prognostic certainty of short-term mortality for ED physicians in both health systems. This shows promise in enhancing clinician's confidence in initiating earlier end-of-life discussions.

Instruments for the functional assessment of elderly persons in palliative care: an integrative review

Abstract Objective: to identify validated instruments that can be used for the functional assessment of elderly persons in Palliative Care. Method: an integrative review focused on identifying instruments for the functional assessment of elderly persons in palliative care was carried out by searching publications in periodicals indexed in seven electronic databases. Descriptors, keywords and Boolean operators were used for a cross-database search in November 2017. A total of 357 abstracts were identified, from which 53 articles were selected for reading, of which 21 met the inclusion criteria. Results: this strategy allowed the identification of eight scales and one test for the functional assessment of elderly persons in palliative care. Conclusion: eight scales and a functional test which also provide guidelines for improving the quality of life of elderly people in palliative care were identified, demonstrating that it is practically impossible to disassociate physical functional performance from social and psychological aspects.

Accounting for frailty when treating chronic diseases

Chronic diseases are considered to be major determinants of frailty and it could be hypothesized that their treatment may counteract the development of frailty. However, the hypothesis that intensive treatment of chronic diseases might reduce the progression of frailty is poorly supported by existing studies. In contrast, some evidence suggests that intensive treatment of chronic diseases may increase negative health outcomes in frail older adults. In particular, if treatment of symptoms related to chronic diseases (i.e. pain in osteoarthritis, dyspnoea in respiratory disease, motor symptoms in Parkinson disease) might potentially reverse frailty, the benefits related to preventive pharmacological treatment of chronic diseases (i.e. antihypertensive treatment) in patients with prevalent frailty is not certain. In particular, several factors might alter the risk/benefit ratio of a given treatment in persons with frailty. These include: exclusion of frail persons from clinical studies, reduced life expectancy in frail persons, increased susceptibility to iatrogenic events, and functional deficits associated with frailty. Therefore, frailty acts as an effect modifier, by modifying the risks and benefits of chronic disease treatments. This hypothesis must be considered and tested in future clinical intervention studies and clinical guidelines should provide specific recommendations for the treatment of frail people, underlining the pros and the cons of pharmacological treatment and possible targets for therapy in this population. Meanwhile, in older patients, the prescribing process should be individualized and flexible.

Frailty trajectories to identify end of life: a longitudinal population-based study

BACKGROUND

Timely recognition of the end of life allows patients to discuss preferences and make advance plans, and clinicians to introduce appropriate care. We examined changes in frailty over 1 year, with the aim of identifying trajectories that could indicate where an individual is at increased risk of all-cause mortality and may require palliative care.

METHODS

Electronic health records from 13,149 adults (cases) age 75 and over who died during a 1-year period (1 January 2015 to 1 January 2016) were age, sex and general practice matched to 13,149 individuals with no record of death over the same period (controls). Monthly frailty scores were obtained for 1 year prior to death for cases, and from 1 January 2015 to 1 January 2016 for controls using the electronic frailty index (eFI; a cumulative deficit measure of frailty, available in most English primary care electronic health records, and ranging in value from 0 to 1). Latent growth mixture models were used to investigate longitudinal patterns of change and associated impact on mortality. Cases were reweighted to the population level for tests of diagnostic accuracy.

RESULTS

Three distinct frailty trajectories were identified. Rapidly rising frailty (initial increase of 0.022 eFI per month before slowing from a baseline eFI of 0.21) was associated with a 180% increase in mortality (OR 2.84, 95% CI 2.34-3.45) for 2.2% of the sample. Moderately increasing frailty (eFI increase of 0.007 per month, with baseline of 0.26) was associated with a 65% increase in mortality (OR 1.65, 95% CI 1.54-1.76) for 21.2% of the sample. The largest (76.6%) class was stable frailty (eFI increase of 0.001 from a baseline of 0.26). When cases were reweighted to population level, rapidly rising frailty had 99.1% specificity and 3.2% sensitivity (positive predictive value 19.8%, negative predictive value 93.3%) for predicting individual risk of mortality.

CONCLUSIONS

People aged over 75 with frailty who are at highest risk of death have a distinctive frailty trajectory in the last 12 months of life, with a rapid initial rise from a low baseline, followed by a plateau. Routine measurement of frailty can be useful to support clinicians to identify people with frailty who are potential candidates for palliative care, and allow time for intervention.